Care home fall victim lay undiscovered for hours

Margaret Aitchison died following a fall in a stairwell at Broom Lane Care Home, a coroner has found

A care home resident who died after falling down the stairs of a fire escape route had not been checked on by staff for several hours before she was found, a coroner has said.

Margaret Aitchison was found hypothermic on the morning of 16 December 2022 in a stairwell which led to an emergency exit at Broom Lane Care Home in Rotherham.

A 22:30 GMT the previous night, a false fire alarm had been triggered at the home and it was not clear if residents had later been regularly checked on to ensure they were in their beds, a report by coroner Nicola Mundy found.

Mrs Aitchison, who lived on the first floor of the home, died from a fall having suffered "multiple traumatic injuries", Ms Mundy concluded.

She had been found at about 06:30 GMT - several hours after the fire alarm had sounded - at the bottom of an unheated stairway,

Ms Mundy, senior coroner for South Yorkshire east, said in her Prevention of Future Deaths report concerning the incident that there was "conflicting evidence as to the resident checks carried out after the alarm had sounded".

She added that her inquiries had found "there were either no, or inadequate, resident checks following the reactivation of the alarm" and it was thought that not all the fire exits had subsequently been checked.

Sleep checks on residents should have taken place every two hours, but that may also not have happened, the coroner added.

'Fell down stairs'

It was only after 06:00 GMT that carers found Mrs Aitchison was no longer in her room, triggering a 30-minute search of the home.

"She had somehow accessed what should have been a locked fire door on the landing area and having gone through, fell down the stairs sustaining traumatic injuries from which she died," Ms Mundy said in her report.

Mrs Aitchison was hypothermic when she was found, with the outside temperature "about -5 degrees", the report found.

One of the witnesses who gave evidence during the inquest into Mrs Aitchison's death said despite new systems being put in place at the home, there were still no formal checks carried out and "matters hadn't changed" despite the care home manager claiming training had been given out.

Concluding her report, Ms Mundy invited the care home to consider further training of senior staff and a requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations.

She also recommended the training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits.

The company which runs the home, Pristine Care Group Ltd, has been approached by the BBC for comment.

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